Falcon Heights Rehabilitation And Nursing Llc

F-F555: the facility failed to inform and obtain consent from the residents and/or their responsible party when the corporation changed primary medical groups.

The DON said it took over a month for the new medical group to enter the facility and see residents. She said

the new medical group would not return calls to nursing overnight or on the weekends. She said she directed

the nurses to contact the retired medical director (RMD) to receive care instructions if they had not received

a call back within 15 minutes. She said she was frustrated and the nurses on the floor were frustrated the new physician group would not return calls after hours. The DON said it had the potential for negative outcomes for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The RMD was interviewed on 7/31/24 at 11:30 a.m. The RMD said the corporation of the facility decided to change primary medical groups in the facility, along with taking over all of his residents without the resident's Level of Harm - Minimal harm or or their responsible parties' consent. potential for actual harm

The RMD said the nurse had reached out to him on 6/4/24 for treatment orders for Resident #9 since the Residents Affected - Few on-call physicians did not call her back after leaving multiple messages. He said since Resident #9 was not his patient, he did not feel comfortable treating her over the phone so he sent orders to send her out to the emergency room to get checked out. He said the professional standard of care would be to see a resident within 24 to 48 hours after hospitalization . He said it was his understanding that Resident #9 was not seen for more than 10 days after her initial change of condition on 6/4/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50853

Residents Affected - Some Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for three (#35, #43 and #66) of eight residents out of 49 sample residents.

Specifically, the facility failed to:

-Ensure safe smoking practices were followed, including adequate supervision, for Resident #35;

-Ensure a thorough investigation was completed after Resident #35 burned her fingers while smoking; and,

-Ensure medications were not left at the bedside without appropriate self-administration assessments for Resident #35, Resident #43 and Resident #66.

Findings include:

I. Facility policy and procedure

The Smoking policy, dated 5/10/23, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:44 p.m. It read in pertinent part,

Supervised smokers shall not be permitted to smoke without the direct supervision of a designated staff member, family member or volunteer. Direct supervision will be provided throughout the entire smoking period.

The Medication Administration policy, dated 2/29/24, was provided by the NHA on 7/31/24 at 4:44 p.m. It read in pertinent part,

Medications are administered in accordance with written orders of the attending physician or physician extender,

Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guidelines for self-administration of medication.

The Self-Administration of Medication policy, dated February 2021, was provided by the NHA on 7/31/24 at 4:44 p.m. It read in pertinent part,

As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 II. Resident #35

Level of Harm - Minimal harm or A. Resident status potential for actual harm Resident #35, age less than 65, was admitted on [DATE REDACTED]. According to the July 2024 computerized physician Residents Affected - Some orders (CPO), diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing) following cerebral infarction, bipolar disorder, post-traumatic stress disorder and ataxia (neurological disorder causing lack of coordination and tremors).

The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 15 out of 15. The assessment indicated Resident #35 needed set-up assistance for eating and substantial assistance for personal hygiene and dressing.

B. Resident observations

On 7/29/24 at 5:48 p.m. a medication cup containing three medication capsules was observed on Resident #35's overbed table. The resident was sitting in her wheelchair at the table waiting for her supper.

On 7/31/24 at 8:31 a.m. a medication cup containing three medication capsules was observed on Resident #35's overbed table. The resident said it was her Creon (a medication used to treat insufficient pancreas function) and the night nurse left it for her to take with breakfast. Resident #35 was observed taking the medications without assistance.

C. Resident interviews

Resident #35 was interviewed on 7/29/24 at 2:44 p.m. She said she burned her fingers while smoking about

a month ago (June 2024). Resident #35 said when she burned her fingers she was smoking a cigarette and was unsupervised.

Resident #35 was interviewed again on 7/31/24 10:52 a.m. Resident #35 said the nurses brought her Creon medication and left it on her table because she wanted it right when her meal came and the nurse was usually in the dining room at that time. She said sometimes she could take it herself and sometimes the nurse had to come back and help her due to her tremors. Resident #35 said usually stayed in her room until

she took the medication. She said if she left her room before she took the medications, her roommate watched the pills for her.

D. Record review

The July 2024 CPO included a physician's order, dated 4/2/24, to give Resident #35's Creon to keep at bedside with meals so the resident could take the medication after the first bites of food.

-The order was discontinued on 7/29/24, during the survey.

-A review of Resident #35's electronic medical record (EMR) did not reveal a self-administration assessment was completed for the resident to self-administer the Creon, nor was it indicated on the resident's comprehensive care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The smoking assessment, completed 6/7/24 indicated Resident #35 was an unsafe smoker and required supervision. Level of Harm - Minimal harm or potential for actual harm According to a progress note, dated 6/10/24, Resident #35 reported two burns to the nurse. The burns were located on her right second finger measuring 1 centimeter (cm) by 0.8 cm by 0.2 cm and on her right third Residents Affected - Some finger measuring 3 cm x 1 cm x 0 cm.

The risk management report, completed 6/10/24, indicated Resident #35 said she burned herself while smoking but did not know when it happened. According to the report, the resident obtained cigarettes from other sources and smoked on her own at times.

-There was no documentation to indicate the facility had thoroughly investigated how or when Resident #35 burned her fingers when smoking.

E. Staff interviews

Licensed practical nurse (LPN) #5 was interviewed on 7/31/24 at 3:01 p.m. LPN #5 said she was the nurse for Resident #35. She said nurses left the Creon medication for Resident #35 so she could take it when her meal arrived. LPN #5 said the night nurse left the medication on the overbed table this morning (7/31/24) around 7:25 a.m.

-Resident #35 was not observed taking the medication until 8:31 a.m.

The DON was interviewed on 7/31/24 at 2:35 p.m. The DON said Resident #35 came to her and showed her

the burns on her fingers on 6/10/24. The DON said she did not know how the burns happened because Resident #35 was only supposed to be smoking electronic cigarettes at that time. The DON said the facility did not interview the staff who had taken Resident #35 out for smoke breaks to determine if she was smoking regular cigarettes prior to the burns being found.

The DON said all of Resident #35's smoking materials should be locked up in a lock box or with the nurse and she should not have a lighter. The DON said Resident #35 sometimes got cigarettes from her roommate or other residents and she sometimes left the building with friends and would smoke regular cigarettes with them.

The DON was interviewed again on 7/31/24 at 3:07 p.m. The DON said the nurses were leaving the Creon medication at the bedside for Resident #35 about one half hour before meals. However, the DON said the physician's order had been discontinued on 7/29/24 because Resident #35 was too shaky and needed assistance with taking her medication. The DON said the Creon should not have been left at the bedside today (7/31/24).

-The Creon was left at the bedside 7/29/24 and 7/31/24, after the order had been discontinued.

Certified nurse aide (CNA) #7 was interviewed on 7/31/24 at 1:10 p.m. CNA #7 said she knew who the regular smokers were and which residents needed a smoking apron. She said there was not a list of who was a supervised smoker because all smokers were to be supervised and could go out only during smoking times. CNA #7 said Resident #35 was a supervised smoker when she burned her fingers. CNA #7 said she did not know how it happened but said Resident #35 was only able to smoke electronic cigarettes now.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The NHA was interviewed on 7/31/24 at 2:11 p.m. The NHA said a smoking assessment was completed quarterly for all residents. The NHA said if a resident was a safe smoker they could go outside to smoke Level of Harm - Minimal harm or anytime and they had a lock box in their room to keep smoking materials. The NHA said if a resident was potential for actual harm determined to be an unsafe smoker the staff kept their smoking materials and they could go outside to smoke only at designated times with staff supervision. Residents Affected - Some

The NHA said staff must stay with the supervised smokers the entire time the residents were smoking. The NHA said she did not recall what was found on the accident investigation for Resident #35.

38185

III. Resident #43

A. Resident status

Resident #43, age 76, was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the July 2024 CPO, diagnoses included chronic kidney disease, post-traumatic stress disorder, major depressive disorder, anxiety disorder, low back pain and restless leg syndrome.

The 7/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15.

She required set up assistance with activities of daily living (ADL).

B. Resident interview and observations

On 7/29/24 at 11:16 a.m. Resident #43 was lying in bed watching television. On the overbed table, next to

the resident's bed, three different bottles of eye drops were observed, along with a bottle of nasal spray and dairy relief pills.

Resident #43 said her eyes were really dry and she administered the eye drops daily. She said she used the nasal spray a couple of times per week and she took the dairy relief pills when she ate anything that consisted of dairy products.

On 7/30/24 at 4:15 p.m. Resident #43 was lying in bed watching television. Resident #43 described the three bottles of eye drops as Systane Lubricant eye drops, Systane Gel eye drops and Eye Allergy Itch Relief (Olopatadine Hydrochloride Ophthalmic Solution). She said the Systane eye drops were given to her by her ophthalmologist and her family member provided her with the allergy eye drops. Resident #43 said she used both of the Systane eye drops after she was given the prescription eye drops by the nurse every day.

Resident #43 said the nasal spray was Deep Sea Premium Saline, which she used when her allergies were acting up. She said she used the Dairy Relief Lactase Enzyme/Dietary Supplement whenever she consumed food with dairy products.

During the interview with Resident #43, Resident #55, who had severe cognitive impairment and a documented history of wandering, entered Resident #43's room. Resident #55 was speaking Spanish and appeared aggressive. Resident #43 told Resident #55 to leave her room in Spanish. Resident #55 continued to come into the room, until Resident #43 continued to yell, vamanos, vamanos, vamanos. Resident #55 ended up leaving Resident #43's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident #43 said Resident #55 and another resident would enter her room quite often. She said the two residents wandered up and down the hallways, entering everyone's rooms. Level of Harm - Minimal harm or potential for actual harm Resident #43 said her roommate, Resident #66, tried to give her some Aspercreme spray, but she did not think it was right to use since she did not know what it was (see observations below for Resident #66). Residents Affected - Some C. Record review

-The July 2024 CPO did not reveal a physician's order for the Systane Lubricant eye drops, the Systane Gel eye drops, Eye Allergy Itch Relief eye drops, Deep Sea Premium Saline nasal spray or Dairy Relief Lactase Enzyme/Dietary.

-A review of Resident #43's EMR did not reveal a self-administration assessment was completed for the resident to self-administer medications, nor was it indicated on the resident's comprehensive care plan.

IV. Resident #66

A. Resident status

Resident #66, age 71, was admitted on [DATE REDACTED] and readmitted [DATE REDACTED]. According to the July 2024 CPO,

diagnoses included chronic respiratory failure with hypoxia (progressive condition that occurs when the airways to the lungs become damaged and narrow, restricting airflow and oxygen intake), polyneuropathies (damage to peripheral nerves), pain in the left shoulder and displaced fracture of the lateral end of the left clavicle.

The 7/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15.

She was independent with all ADLs.

B. Resident interview and observations

On 7/29/24 at 11:16 a.m. Resident #66 was lying in bed watching television. Resident #66 and Resident #43 were

roommates. On Resident #66's overbed table, a can of Aspercreme Lidocaine maximum strength dry spray was observed with the lid off.

Resident #66 said she used the Aspercreme Spray when she was having muscle pain.

C. Record review

-The July 2024 CPO did not reveal a physician's order for the Aspercreme Lidocaine Spray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -A review of Resident #66's EMR did not reveal a self-administration assessment was completed for the resident to self-administer the Aspercreme Spray, nor was it indicated on the resident's comprehensive care Level of Harm - Minimal harm or plan. potential for actual harm V. Staff interviews Residents Affected - Some LPN #5 was interviewed on 7/30/24 at 4:25 p.m. LPN #5 said she did not know if residents should have medications at the bedside. She said she did not know who was responsible for conducting self-administration assessments. LPN #5 said she was not sure if either Resident #43 or Resident #66 had a self-administration assessment. She said she did not know how to find that information.

The DON was interviewed on 7/31/24 at 11:20 a.m. The DON said all medications kept at the bedside should have a physician's order for self administration, a self-administration assessment completed and be noted on

the comprehensive care plan. She said all medications that the resident requested to have in their room should be kept in a lock box to ensure another resident did not access them by accident.

The DON said Resident #43 did not have a physician's order to self-administer medications nor a physician's order for the eye drops, nasal spray and daily relief supplement. She said Resident #66 did not have a physician's order to self-administer medications nor a physician's order for the Aspercreme Lidocaine spray.

The DON said the facility did not complete self-administration assessments for Resident #43 and Resident #66. She said the comprehensive care plan did not include self-administration for Resident #43 and Resident #66.

The DON said the facility was in the process of obtaining physician's orders for the medications, completing

the self-administration assessments, updating the comprehensive care plans and providing lock boxes for Resident #43 and Resident #66.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38185 potential for actual harm Based on record review and interviews, the facility failed to manage pain for one (#43) of two residents out of Residents Affected - Few 49 sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Specifically, the facility failed to provide pain relieving cream to Resident #43 as ordered by the physician.

Findings include:

I. Facility policy and procedure

The Pain Management policy and procedure, dated May 2023, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:44 p.m. It revealed in pertinent part, Pain is subjective and is what the resident says it is, existing when and where the resident says it does.

Around the clock dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent analgesic administration.

II. Resident #43

A. Resident status

Resident #43, age 76, was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the July 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease, post-traumatic stress disorder, major depressive disorder, anxiety disorder, low back pain and restless leg syndrome.

The 7/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 15 out of 15. She required set up assistance with activities of daily living (ADL).

The assessment indicated the resident received a scheduled pain medication regimen and the resident had almost constant pain. The pain occasionally made it hard for her to sleep at night and frequently limited her daily activities.

The assessment indicated her worst pain during the past five days of the assessment period was 3 out of 10.

B. Resident interview

Resident #43 was interviewed on 7/29/24 at 11:16 a.m. Resident #43 said she had arthritis which caused her pain daily. She said she had arthritis pain in her wrists, neck, lower back, hips and arms. She said she was supposed to receive a cream four times per day, however, she said she had not received it today (7/29/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Resident #43 was interviewed again on 7/30/24 at 4:15 p.m. She said she still had not received her arthritis cream. She said she had a hard time with licensed practical nurse (LPN) #5 administering her medications. Level of Harm - Minimal harm or She said she was not surprised she had not received the arthritis cream because that particular nurse was potential for actual harm working.

Residents Affected - Few Resident #43 said the arthritis cream really helped with her pain but since she had not received it she felt achy all over.

C. Record review

The pain care plan, initiated on 6/28/23 and revised on 7/12/24, revealed Resident #43 reported she had pain with contributing factors such as kidney disease, depression, osteoporosis and restless leg syndrome.

The interventions included administering analgesia per physician's orders.

The 6/30/24 pain evaluation documented the resident had chronic lower back pain and said she had been told she had arthritis. She described the pain as throbbing. It indicated the resident experienced pain to the left hip, left knee, lower back, neck and shoulders. The resident's acceptable level of pain was 3 out of 10.

The resident's pain was relieved by medication, relaxation, position changes and diversional activities. It indicated that the resident was on a scheduled pain medication regimen with scheduled Tylenol and she had scheduled Biofreeze gel four times per day.

The July 2024 CPO documented the following physician's orders:

Biofreeze External Gel 4% (percent) topical analgesic: apply to neck, lower back and hips topically four times

a day for pain, ordered 4/11/24.

The July 2024 medication administration record (MAR) documented that the resident was administered the Biofreeze External Gel four times on 7/29/24 and three times on 7/30/24.

-However, according to the resident, who was alert and oriented, she had not received the topical analgesic (see resident interview above).

III. Staff interviews

LPN #5 was interviewed on 7/30/24 at 4:25 p.m. LPN #5 said she administered Resident #43 received Biofreeze three times per day. She said she could not remember if she had administered the medication that day (7/30/24). She said Resident #43 was alert and oriented and the resident was usually right which meant

she probably did not administer the medication that day.

LPN #5 said the July 2024 MAR documented that the medication was given on 7/30/24. She said she should not have marked off the medication as given on the MAR when she did not administer the medication.

LPN #5 pulled out the Biofreeze gel and began pumping it into a medication cup. She said she would call the physician and make a note in the resident's electronic medical record (EMR) that the medication was not given as indicated on the MAR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 The director of nursing (DON) was interviewed on 7/30/24 at 5:01 p.m. The DON said medications should be given as ordered by the physician. She said medications should not be signed off as given if they were not Level of Harm - Minimal harm or administered. potential for actual harm

The DON said LPN #5 should not have signed off the medication as given on the MAR if she did not Residents Affected - Few administer the Biofreeze gel. She said she should have contacted the physician and made a note in the resident's EMR. She said she would conduct a medication error investigation and provide education immediately to LPN #5.

The DON said she was concerned what other medications LPN #5 might not have administered but had signed off as she had.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50853 potential for actual harm Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication Residents Affected - Few error rate of five percent (%) or greater.

Specifically, the medication administration observation error rate was 8%, or two errors out of 25 opportunities for error.

Findings include:

I. Professional reference

According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 8/1/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment.

Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication.

II. Facility policy and procedure

The Medication Administration policy, dated 2/29/24, was provided by the nursing home administrator (NHA)

on 7/31/24 at 4:44 p.m. The policy read in pertinent part,

Medications are administered in accordance with written orders of the attending physician or physician extender.

Verify the medication label against the medication administration record (MAR) for accuracy of drug frequency, duration, strength, and route.

Double-check the amount of medication to be administered.

Medication is to be given in compliance with physician orders and or manufacturer's recommendations.

III. Manufacturer's Guidelines

According to the manufacturer's guidelines for Lexapro (escitalopram oxalate), retrieved on 8/1/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021323s047lbl.pdf,

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Lexapro is an orally administered selective serotonin reuptake inhibitor (SSRI) used to treat depression and anxiety. The recommended dose for elderly patients is 10 milligrams. Level of Harm - Minimal harm or potential for actual harm According to the manufacturer's guidelines for levothyroxine sodium, retrieved on 8/1//24 from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl. Residents Affected - Few cfm?setid=a8db0f7d-8863-9309-e053-2995a90a284a&type=display, Administer once daily, preferably on an empty stomach, one half to one hour before breakfast.

IV. Observations and interviews

On 7/31/24 at 9:21 a.m. licensed practical nurse (LPN) #2 was preparing and administering medications for Resident #45.

Resident #45 had a physician's order for Lexapro five milligrams (mg) two tablets by mouth one time a day, ordered on 7/4/24. The medication was scheduled for 8:00 a.m.

Resident #45 had a physician's order for levothyroxine sodium 150 micrograms (mcg) one tablet by mouth in

the morning for hypothyroidism, ordered on 4/18/24. The medication was scheduled for 8:00 a.m.

LPN #2 took the card of Lexapro from the medication cart and punched one five mg tablet into the medication cup. She administered one tablet to Resident #45. Upon prompting when LPN #2 returned to the medication cart, she reread the physician's order.

LPN #2 said the physician's order was for two tablets and she should have given Resident #45 two tablets. LPN #2 obtained another five mg tablet of Lexapro from the medication cart and administered it to the resident.

LPN #2 took the levothyroxine sodium 150 mcg from the medication cart and administered it to Resident #45 at 9:29 a.m. Resident #45 had an empty breakfast plate on his bedside table and said he finished breakfast.

The levothyroxine sodium was scheduled to be administered at 8:00 a.m., however, LPN #2 administered

the medication at 9:29 a.m., which was 89 minutes after it was scheduled and after the resident had already eaten breakfast.

LPN #2 said levothyroxine sodium should be given on an empty stomach.

V. Additional staff interviews

The director of nursing (DON) was interviewed on 7/31/24 at 4:00 p.m. The DON said levothyroxine sodium should be administered on an empty stomach. She said medications should be administered according to

the physician's order.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 50853 Residents Affected - Some Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in three of five medication carts and one of two medication storage rooms.

Specifically, the facility failed to:

-Ensure medications were properly labeled with open dates; and,

-Ensure expired medications were removed from the medication carts and the medication storage room.

Findings include:

I. Professional reference

The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 8/6/24 from https://www.fda. gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.

II. Observations

On 7/31/24 at 8:48 a.m. the medication cart on the 200 hallway was observed with licensed practical nurse (LPN) #2. The following item was found:

-An open Tresiba FlexTouch insulin pen 100 units/milliliter was not labeled with the date it was opened.

On 7/31/24 at 9:47 a.m. the medication cart on the 500 hallway was observed with LPN #4. The following item was found:

-One bottle of liquid haloperidol 2 milligrams (mg)/milliliter (ml) that expired on 6/24/24.

On 7/31/24 at 10:14 a.m. the medication storage room was observed with the director of nursing (DON). The following item was found in the refrigerator:

-Three one mg vials of lorazepam liquid 2 mg/ml single dose that expired on 4/18/24.

On 7/31/24 at 11:24 a.m. the medication cart on the 300 hallway was observed with LPN #3. The following items were found:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 -One bottle of Tylenol 500 mg that expired in June 2024; and,

Level of Harm - Minimal harm or -One bottle of Stress Formula vitamin supplement that expired in April 2024. potential for actual harm

On 7/31/24 at 11:46 a.m. the medication cart on the 200 hallway was observed with LPN #2. The following Residents Affected - Some item was found:

-One vacutainer blood collection needle that expired 10/31/23.

III. Staff interviews

LPN #2 was interviewed on 7/31/24 at 8:48 p.m. LPN #2 said the insulin pen should have been dated when it was opened. LPN #2 said she was unsure how long an insulin pen was good for after it was opened.

LPN #3 was interviewed on 7/31/24 at 11:24 a.m. LPN #3 said he checked for expired medications in the cart. He said the expired medications should have been removed from the medication cart.

The director of nursing (DON) was interviewed on 7/31/24 at 4:00 p.m. The DON said the expired medications and supplies should have been removed from the medication storage room refrigerator and medication carts. The DON said the insulin pen should have been dated when it was opened.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47150 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure residents consistently Residents Affected - Many receive food prepared by methods that conserved nutritive value and was palatable in taste, texture, appearance and temperature.

Specifically, the facility failed to ensure the residents' food was palatable in taste, texture, appearance and temperature.

Findings include:

I. Resident interviews

Resident #24 was interviewed on 7/29/24 at 9:00 a.m. Resident #24 said he preferred eating in his room. He said the room trays were always delivered about 15 minutes to 45 minutes late. Resident #24 said he received a texture modified diet and sometimes the staff delivered the wrong diet tray to him.

Resident #21 was interviewed on 7/29/24 at 9:02 a.m. Resident #21 said she only ordered hamburgers and hot dogs from the kitchen because the rest of the food did not taste good. She said the hot dogs and hamburgers were usually served cold. She said they put barbeque sauce on the hamburgers and it did not taste right.

Resident #51 was interviewed on 7/29/24 at 10:14 a.m. Resident #51 said the food tasted terrible and was always served late. He said the staff would always forget to provide condiments and he would have to ask

the staff to get some for him. He said the tray sat longer and got cold while he waited for staff to bring him

the condiments.

Resident #40 was interviewed on 7/29/24 at 10:23 a.m. Resident #40 said the food tasted bad and was always served late. He said he went to dialysis every Monday, Wednesday and Friday. He said he left the facility at 4:30 p.m. and did not return until 9:45 p.m. He said the kitchen staff often forgot to make his dinner to take with him for his appointments and they would then offer him a peanut butter sandwich. Resident #40 said the sandwich often did not hold him and he would return to the facility feeling hungry. He said he got sick at the entrance of the facility when he returned from dialysis due to not eating enough food before his appointments.

Resident #66 was interviewed on 7/29/24 at 11:19 a.m. Resident #66 said the food did not taste right and had no flavor. She said the drinks were watered down.

Resident #5 was interviewed on 7/31/24 at 2:15 p.m. Resident #5 said the food was awful and tasted bad.

He said he ate his meals in his room and the food was delivered to him cold. Resident #5 said the encrusted pork loin was overcooked and tasted dry. He said the gravy did not taste right because it tasted as if it was missing seasoning.

II. Test tray

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 A test tray for a regular diet and pureed diet was evaluated by four surveyors immediately after the last resident had been served their room tray for lunch on 7/31/24 at 1:22 p.m. Level of Harm - Minimal harm or potential for actual harm The regular texture test tray consisted of encrusted pork loin, mashed potatoes, cabbage vegetables, diner rolls and sweet potatoes. The following observations were made: Residents Affected - Many -The encrusted pork loin was dry;

-The mashed potatoes were bland;

-The gravy on the mashed potatoes and the pork loin tasted bland and was watery; and,

-The cabbage vegetables were bland and mushy.

The pureed texture test tray consisted of puree pork loin, mashed potatoes, puree cabbage, puree sweet potatoes with gravy and pureed green peas. The following observations were made:

-The mashed potatoes tasted bland;

-The gravy was watery and tasted bland; and,

-The pureed pork loin tasted mushy and dry.

III. Staff interviews

The dietary account director (DAM) and the regional dietary manager (RDM) were interviewed together on 7/31/24 at 1:50 p.m. The DAM said he noticed the encrusted pork loin was a little overcooked. He said, because it was almost time to begin serving lunch, he did not have time to fix it.

The DAM said the kitchen was running out of gravy in the middle of serving lunch so cook (CK) #1 asked him to prepare additional gravy. He said the additional gravy came out a little watery because it was prepared very quickly. The DAM said the cooks should always ensure they had enough of every menu item according to the census of the facility.

The DAM said the kitchen staff should always taste the food items they prepared for the residents to ensure

the appropriate texture and taste were obtained before serving the food to the residents.

The RDM said it was important to ensure the right food texture and taste were obtained to avoid residents not eating their food, which could help to prevent unwanted weight loss. The RDM said more education would be provided immediately to the kitchen staff in regards to food preparation and palatability.

The nursing home administrator (NHA) was interviewed on 7/31/24 at 2:50 p.m. The NHA said more education would be provided immediately to all kitchen staff and a monitoring plan would be initiated to ensure staff complied with the facility's food preparation protocol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 43 065168 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 47150

Residents Affected - Many Based on observations, record review and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen.

Specifically, the facility failed to ensure staff correctly and accurately tested for the correct parts per million (ppm) of the dishwasher, chemical sanitizer solution of the three sink compartments and sanitizer buckets.

Findings include:

I. Professional reference

According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/8/24 from https://drive.google. com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view,

Chemical sanitizers that are used to sanitize equipment and utensils shall be provided and available for use

during all hours of operation.

A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times and be used in accordance with the Environmental Protection Agency (EPA) registered label use instructions.

Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

II. Facility policy and procedure

The Warewashing Kitchen Sanitation policy, revised September 2017, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:35 p.m. It read in pertinent part, All dishware, serviceware, and utensils will be cleaned and sanitized after each use.

The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through

the dish machine, and proper handling of sanitized dishware.

Temperature and sanitizer concentration logs will be completed, as appropriate.

III. Observations and interviews

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 7/29/24 at 9:10 a.m., dishwasher (DW) #1 was in the dishwashing area working on filling a rack with dirty dishes to run through the dishwasher. DW #1 said the dish machine was a low temperature machine. He Level of Harm - Minimal harm or said he checked the chemical concentration of the machine at the beginning of his shift and documented the potential for actual harm outcome on a test trip log hanging on the wall in the dishwashing room. DW #1 ran a test strip through the dishwasher and the strip registered 10 ppm. The DW said the solution tested 100 ppm in the morning Residents Affected - Many (7/29/24) and the machine needed to be primed.

DW #1 said the solution in the red and green buckets was used to clean equipment and surfaces in the food preparation area and the dining room.

The solution in the bucket was tested with a test strip by the DW. The solution registered 10 ppm on the strip.

Dietary aide (DA) #1 said she did not check the chemical concentration of the sanitizer when she filled the bucket with the sanitizer solution.

The dietary account manager (DAM) said the kitchen had an automatic solution dispenser that mixed the solution with water. He said they did not tamper with the dispenser and would call (name of company) for all maintenance issues.

The DAM said the staff used the machine to fill the red sanitizer buckets. He said the staff needed to test the solution each time they filled the buckets to ensure the strength of the solution was correct by testing the ppm. He said the kitchen staff should document the test strip result each time they filled the red sanitizer buckets, however, he said there was no test strip log for the red sanitizing buckets.

At 9:30 a.m. the DAM tested the three sink compartment chemical sanitizer solutions with a test strip and it registered 200 ppm.

The DAM said he called the (name of company) who were the manufacturers of the dispenser and the chemical sanitizing solution. DW#1 primed the dishwasher and completed another test strip which measured 100 ppm.

IV. Record review

A review of the July 2024 (7/1/24 to 7/29/24) sanitizing test strip log on 7/31/24 at 9:50 a.m. revealed the log was completed once a day in the morning.

The label on the sanitizing chemical solution dispenser read (Oasis multi quat sanitizer) the concentration of

the sanitizer should measure 150 ppm.

The manufacturer's recommendation from the (name of company) technician was to test the ppm at least three times a day to ensure the accuracy of the chemical solution.

V. Staff interviews

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The DAM and the regional dietary account manager (RDM) were interviewed together on 7/30/24 at 3:55 p. m. The DAM said he had noticed the testing strip was completed only once a day when he started as the Level of Harm - Minimal harm or manager a few weeks ago, which was contrary to the manufacturer's recommendation for testing at least potential for actual harm three times per day.

Residents Affected - Many The DAM said he was now aware of the recommendation and would follow the manufacturer's recommendations of running the test strip at least three times a day.

The RDM said the facility would immediately educate the kitchen staff on how to test the quat solution correctly and would ensure testing strips were completed and documented accurately.

The NHA was interviewed on 7/31/24 at 2:50 p.m. The NHA said the kitchen staff should ensure the chemical sanitizing solution was measured accurately before using it on equipment and surfaces in the food preparation area and in the dining room where residents ate. She said testing needed to be conducted accurately to ensure surfaces were sanitized appropriately to avoid contaminating the food preparation areas.

The NHA said she would immediately reach out to (name of company) to offer additional training for the kitchen staff on the proper use and maintenance of the dishwasher and the management of the testing strips.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50315 potential for actual harm Based on observation, record review and interviews, the facility failed to establish a sanitary environment to Residents Affected - Some help prevent the transmission of communicable diseases and infections on three of five hallways.

Specifically, the facility failed to:

-Ensure nursing staff completed proper hand hygiene during medication pass; and,

-Ensure housekeeping completed proper hand hygiene when cleaning resident rooms.

Findings include:

I. Failure to ensure nursing used proper hand hygiene during medication pass

A. Observations

On 7/29/24 at 4:24 p.m. registered nurse (RN) #1 was observed preparing and administering medication for three residents in the 300 hall.

-RN #1 did not perform hand hygiene prior to preparing medication or between administering medication to

the residents.

On 7/30/24 at 11:50 a.m. licensed practical nurse (LPN) #3 was observed preparing and administering medication to four residents in the 300 hall.

-LPN #3 did not perform hand hygiene prior to preparing or between administering medication to the residents.

B. Staff interviews

RN #1 was interviewed on 7/29/24 at 4:24 p.m. RN #1 said she should have performed hand hygiene between preparing medications for each resident.

LPN #3 was interviewed on 7/30/24 at 11:50 a.m. LPN #3 said he should have performed hand hygiene between preparing medications for each resident.

The director of nursing (DON) was interviewed on 7/31/24 at 4:00 p.m. The DON said the nurses should perform hand hygiene when preparing and administering medications. She said hand hygiene should be performed between preparing medications for each resident.

II. Failure to ensure housekeeping used the proper hand hygiene when cleaning resident rooms

A. Observations

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Housekeeper (HSK) #1 was observed on 7/30/24 at 11:08 a.m. HSK #1 was beginning to clean room [ROOM NUMBER]. She cleaned the bathroom by wiping down the grab bar, wiping the toilet and cleaning Level of Harm - Minimal harm or the inside of the toilet. She disposed of the dirty rag. potential for actual harm -Without changing gloves or performing hand hygiene, HSK #1 applied a clean mop head to the mop. She Residents Affected - Some then mopped the bathroom. She disposed of the dirty mop head.

-Without performing hand hygiene or changing her gloves, HSK #1 proceeded to sweep the room. She applied a clean mop head to the mop and mopped side B of the room.

-She disposed of the dirty mop and applied a clean mop head to the mop without performing hand hygiene or changing her gloves She mopped side A of the room. She removed her gloves and performed hand hygiene when she was finished mopping the room.

HSK #1 moved to the next room down the hallway and applied gloves. She cleaned the bathroom by wiping down the grab bar, wiping the toilet and cleaning the inside of the toilet. She disposed of the dirty rag.

-Without performing hand hygiene or changing her gloves, HSK #1 applied a clean mop head to the mop.

She then mopped the bathroom. She took the dirty mop head off and disposed of it. She then swept the room. She applied a clean mop head to the mop and mopped side B of the room. She disposed of the dirty mop and applied a clean mop head to the mop without changing gloves or performing hand hygiene. She mopped side A of the room.

-HSK #1 failed to perform hand hygiene or change her gloves during the whole process of mopping the bathroom and then cleaning both sides of the room.

B. Staff interviews

The infection preventionist (IP) was interviewed on 7/31/24 at 10:00 a.m. The IP said the housekeeping staff should remove gloves, perform hand hygiene and apply new gloves between moving from room to room.

She said they should have completed hand hygiene after cleaning the bathroom.

50853

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065168 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0923 Have enough outside ventilation via a window or mechanical ventilation, or both.

Level of Harm - Minimal harm or 47150 potential for actual harm Based on observations and interviews, the facility failed to provide adequate ventilation by means of Residents Affected - Some mechanical ventilation for three of four resident shower rooms.

Specifically, the facility failed to ensure exhaust fans in resident shower rooms were functioning efficiently.

Findings include:

I. Facility policy and procedure

The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:35 p.m. The policy read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment.

The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting such as institutional odors.

II. Observations

An observation of the resident's environment was completed on 7/30/24 at 2:40 p.m. and 7/31/24 at 10:15 a. m.

The exhaust fans in the shower rooms on the 300 hall, the 400 hall and the 600 hall had no audible sound and were not functioning effectively. The shower rooms had a strong urine odor and were humid.

III. Staff interviews

The maintenance supervisor (MS) and the NHA were interviewed together on 7/31/24 at 10:30 a.m. The MS said the exhaust fans and ventilation maintenance had not appeared on the system he used to track maintenance and repairs, so he was not aware the exhaust fans were not functioning appropriately.

The NHA said the shower room exhaust fans should be in good working condition to eliminate odors in the resident's shower rooms.

The NHA said she would immediately include the exhaust fans in the shower rooms as part of an ongoing quality improvement plan which would include periodic checks on all ventilation systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 43 065168